Across the Americas, as many as 4 million persons may become infected with Zika virus by early 2017, according to World Health Organization estimates. Most infections will occur outside of North America, where abortion is generally illegal, even for women infected during their pregnancies.

In response to the Zika virus epidemic, Latin American pregnant women who have no access to legal abortion increasingly turned to an online portal offering medication abortion, reports a study published in The New England Journal of Medicine.[1] The researchers analyzed the trend of requests, finding an increase of 36% to 108% over requests made over the 5 years before advisories alerted women of the dangers of Zika virus during pregnancy.[2] (On June 30, 2016, PAHO published an update stating that 40 countries and territories have confirmed local, vectorial transmission of Zika virus disease in the Region of the Americas since 2015.[3]) The requests were made the online service called Women on Web, a non-profit organization through which physicians prescribe pills such as mifepristone and misoprostol to women early in their pregnancies who live in areas where safe abortion is unavailable.

The researchers compared the trends within a control group, with no expected increase in requests, to the three study groups with legal restrictions on abortion:

Zika outbreak in country?

Health advisory issued?

A

YES

YES

B

NO

NO

C

YES

NO

In the three control-group nations—Chile, Poland, and Uruguay—the researchers found no increase in the number of online requests for abortion pills, indicating that there appeared to be no global increase in requests for reasons other than Zika. The women in study group A increased their number of requests by more than 100% in Brazil and Ecuador, by nearly 50% in Costa Rica and Venzuela, and by a smaller but still statistically significant degree in other nations that had an ongoing Zika virus outbreak and an issued health advisory. The women in study group B showed small increases in requests from Argentina and Peru, and the women in study group C showed no difference in the number of requests. Although the researchers could not directly link Zika-related concerns to the increased demand for abortion pills, the percentage of women reporting Zika fears correlated with the country-specific increases in requests.

What about your patients, here in the United States? No cases of US-acquired mosquito-borne cases have been reported, though cases have been reported in Puerto Rico, the US Virgin Islands, and American Samoa.[4] The U..S Zika pregnancy registry reports that 7 babies born in the United States who were infected outside the United States have been born with microcephaly or other related birth defects. The CDC is monitoring another 287 pregnant women with laboratory evidence of Zika infection.[5] CDC has issued travel notices for pregnant women planning to go to Central and South America and the Carribbean and Pacific Islands.[6] Infection with Zika virus tends to be mild, requiring no specific treatment. For pregnant women, however, the risk is to their fetuses. Unfortunately, the CDC reports that we do not know the likelihood of infection upon a woman’s exposure to the virus.[7] We also do not know the likelihood of the infection passing to an infected woman’s fetus or, if the fetus does become infected, the likelihood of microcephaly or other birth defects. We also do not know if sexually transmitted Zika infection acts differently than mosquito-borne infection. Currently, no vaccine can prevent infection in the fetus or prevent a consequent microcephalic condition.

“As Zika spreads to the United States, women in the states most likely to be hardest hit, including Texas, Florida and Mississippi, face a situation that may not be so different from that of women in Brazil, Venezuela and Ecuador. Abortion access in these U.S. states has been seriously curtailed after a wave of legislation designed to close clinics,” Abigail Aiken, the lead author of the report and assistant professor at the University of Texas at Austin, wrote in the Dallas Morning News.[8] She called upon health organizations and governments to provide timely and accurate information about the risks of Zika in pregnancy and to support access to safe, legal abortions for women who want them.

Contraceptive Technology

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This month’s clinical pearl

December 2018 Clinical Fact:

“Because implants and IUDs are highly effective, they are excellent choices for the short-term, too, and the fact that an implant or an IUD is good for “up to” 3 to 20 years is an added advantage but not always relevant.” — Contraceptive Technology, 21st edition